Categorized | Prostate Treatment

Use Caution When Deciding on HIFU

Normally, high-intensity focused ultrasound (HIFU) is used as a salvage treatment for prostate cancer.  Recently, a movement has taken place to push HIFU as a front-line use, but both the US Food and Drug Administration and the European Association of Urology classify the procedure as experimental.

The first case series to report outcomes in men after failed whole-gland HIFU and salvage radical prostatectomy suggests that there is reason for caution.

Researchers report they were alarmed at the pathology results.  Morbidity appeared to be higher after salvage prostatectomy than after primary surgery.

Declan G. Murphy, MD, from the Department of Urological Oncology at the Peter MacCallum Cancer Centre in Melbourne, Australia, notes, “Whether it is that standard prostate biopsy cannot be relied on to predict final pathological outcome, or that HIFU ‘makes cancer angry,’ patients should be fully counseled about what we know and, importantly, what we do not know about HIFU treatment for localized prostate cancer today.”

“Our own initial experience with HIFU treatment for primary and recurrent prostate cancer unfortunately led us to conclude that the technology is not yet suitable for mainstream clinical practice, and led us to suspend our program,“ Dr. Murphy added.

Dr. Lawrentschuk believes that using radical prostatectomy as salvage treatment after the failure of primary HIFU is feasible; however, he is concerned about the rate of extraprostatic extension.

“HIFU is experimental and should only be done in studies where patients are told of the risks of failure and the poor results of salvage.  They need very careful monitoring, follow-up biopsies, etc.  I do not advise patients to have HIFU.  There may be a problem with HIFU selecting out more aggressive cells, but this warrants further study,” explains Dr. Lawrentschuk.

“Experimental treatments are fraught with danger.  I was surprised at the aggressive nature of the disease and the recurrences in this supposedly low-risk group,” he continues.  “I think HIFU is inadequate in its current form, perhaps because of poor patient selection for HIFU and a lack of standardized ways of detecting post-HIFU recurrences in a timely fashion.”

Howard Sandler, MD, chair of radiation oncology at Cedars-Sinai Medical Center’s Samuel Oschin Comprehensive Cancer Institute in Los Angeles, California, also reviewed the study.

“I wouldn’t conclude that the high number with extracapsular extension is a result of HIFU.  It is more likely that patients who fail HIFU had worse cancers in any case from the start.  Additionally, there may have been a bit of a delay after some suspicion of recurrence before salvage surgery was done, given the presurgery PSA [prostate-specific antigen] of 3.8, with the nadir PSA of 1.0.  Thus, patients waited on average for their PSA to rise from 1.0 to 3.8 before something was done.  During this interval, extracapsular extension may have occurred,” Dr. Sandler explained.

Overall, Dr. Sandler believes that HIFU is a poor choice for whole-gland ablation and focal therapy.

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April 2011
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